Abdominal Flashcards
Describe visceral pain vs. parietal pain
Visceral: organ stretching, not localized
Parietal: Inflammation in the parietal peritoneum, LOCALIZED, aggravated by movement or coughing
What is referred pain? Where does
1) duodenal and pancreatic pain refer to?
2) biliary tree refer to?
Originates within the abdomen but is felt at distant
sites which are innervated at approximately the same spinal levels as the disordered structure
1) back
2) Right shoulder
What are the most important components of oldcarts for an abdominal exam?
LOCATION
Aggravating/Alleviating factors
Focused ROS you should probably ask about?
• GI: nausea, vomiting, diarrhea, black stools, blood in
the stool, blood in the vomit
• GU: dysuria, polyuria, hematuria, flank or CVA pain
GYN: vaginal bleeding, vaginal discharge, LMP, possibility of pregnancy
What other parts of the history are important?
Past surgical history
Current medicines: blood thinners, Narcotics, GI prescriptions, social history (esp. weed), family history
What is the order of the physical abdominal exam?
- Inspection 2. Auscultation 3. Percussion 4. Palpation
What is in the RUQ
Liver, gallbladder, stomach, SB, LB
What is in the RLQ
Appendix, ovary, SB, LB
What is in the LUQ
Stomach, Spleen,, SB, LB
What is in the LLQ
Colon, ovary, SB, LB
What is in the epigastric area?
Pancreas, Liver, gallbladder, stomach, SB, LB
What are you listening for with bowel sounds? What is abnormal?
bell to listen for bruits, 5-34 ‘clicks’/minute
absent sounds (non for 2 minutes): Long-lasting intestinal obstruction, intestinal perforation, mesenteric
ischemia
decreased sounds (none for 1 minute) Post-surgical ileus, peritonitis
increased sounds: Diarrhea, early bowel obstruction
What are high pitched bowel sounds indicative of?
sounds like tinkling (raindrops on metal)
early intestinal obstruction
What does percussion sound like in an abdominal exam? What is an abnormal sound?
Tympany predominates: gas in the GI tract, scattered areas of dullness is normal from fluid and feces
Abnormal: Large dull areas from a mass or enlarged organ OR Protuberant abdomen typanitic throughout may indicate an intestinal obstruction
Describe the organ assessment of the liver? What does it increase vertically? what does it decrease vertically?
– Right midclavicular line, start in RLQ (area of tympany) and percuss cephalad to an area
of dullness= lower border of liver – Right midclavicular line, start in RUQ (area of lung resonance) and percuss caudad toward liver dullness = superior border of liver
– Normal liver vertical span= 6-12 cm
– Vertical span increased with: • Enlarged liver= cirrhosis, lymphoma, hepatitis, right-sided heart failure, amyloidosis, hemachromatosis, Right pleural effusion (falsely increased)
– Vertical span decreased with:
• Shrunken liver = cirrhosis
Describe the organ assessment of the spleen? What does dullness indicate?
– Starting from border of cardiac border of left anterior axillary line, percuss laterally
– If tympany is prominent laterally in midaxillary line, splenomegaly not likely
– Dullness at midaxillary line= splenomegaly
When might you feel the spleen?
normal to feel in 5% of adults
low diaphragm in COPD PTs
Splenomegaly (HPT), mononucleosis
What is a shifting dullness test?
• Percuss the borders of tympany and dullness with patient supine • Then have patient lay on side and percuss borders again
Normal= borders stay the same
Ascites/ positive test= dullness shifts to dependent side and tympany to top side
What is a fluid wave test?
• Test for a fluid wave
• Ask the patient to rest his or her
hands over chest • Have an assistant place the ulnar
aspects of hands midline, then tapone flank sharply with finger tips • Normal= no impulse felt on the other
flank • Ascites/positive test= impulse
transmitted to the other flank
What is teh McBurney’s point tenderness?
draw an imaginary line from ASIS to umbilicus, and palpate
2 inches medial to ASIS on that line • Positive test= tenderness = APPENDICITIS
What is rovsing’s sign
- palpate deeply in LLQ
* Positive test= pain felt in RLQ = APPENDICITIS
What is Murphy’s sign? What is it for?
with right hand, palpate deeply under the patient’s right
costal margin, ask the patient to take a deep breath in, and palpate deeper
• Positive test= sharp increase in tenderness with sudden
stop in inspiratory effort = BILIARY COLIC, cholethilthis
What is Lloyd’s sign? / punch?
Pain to deep percussion in the area of the costovertebral angle. Positive test= pain in the area of the CVA with deep percussion = Pyelonephritis, ureterolithiasis
What is guarding? Voluntary vs involuntary
- Voluntary – patient consciously protects the abdomen when it is palpated
- Involuntary – unconscious contraction of the abdominal wall musculature when abdomen is palpated
What iS VINDICATE
v: vascular
i: infectious/inflammatory
n: neoplasm
d: drugs, degenerative
i: iatrogenic, idiopathic
c: congenital
a: autoimmune, allergic, anatomic
t: trauma
e: endocrine, environment
What is the clinical presentation of cholelithiasis?
Pain sharp, worse after eating greasy food, bilious vomiting, black stools or blood in stool + murphy’s sign
What is the clinical presentation of pancreatitis?
Alcoholics, epigastric pain, nausea and bilious vomitting, constipation, black stools, blood, lipase 27,000!!
What is the clinical presentation of Ureterolithiasis?
Male with Flank pain radiating to R testicle, pink urine, pain with urination, nauseous and bilious vomitting, black stools or blood, get diagnostic testing to see if blockage –> hydronephrosis
What is the clinical presentation of ACUTE APPENDICITIS?
RLQ abdominal pain, worse with movement, 1 episode of vomitting, positive guarding rebounding tenderness, tenderness greatest at McBurney’s point and, WBC elevated, GET CT!
What are the 4 F’s for gallblader to remember? (higher risk population?)
fat
female
fertile
family
What is the Rome Criteria?
Think: constipation criteria
2 of the following over 3 months:
(M)• Manual maneuvering required to defecate
(I)• Sensation of incomplete defecation
(S)• Straining
(T) • Fewer than THREE 3 bowel movements/week
(I)• Lumpy or hard stools (IRREGULAR)
MISTI
What are constipation associated symptoms?
Abdominal bloating Low back pain Tenesmus (anal sphincter contracting by itself…) Pain on defecation
EMERGENT SYM: Rectal bleeding* Abdominal pain* Inability to pass flatus* Vomiting*
What are lifestyle modifications for constipation?
• Increase fiber in diet • Increase water in diet • Use the bathroom right away when you have the urge, don’t “hold it.” • Increase exercise, including walking • Schedule some uninterrupted time every day
Etiology of gastroenteritis
• Infectious agents are the usual cause • Viral (50-70%): 1) Norovirus: uncontrolled vomitting, cruise ship and casinos 2) Rotavirus: severe dehydration • Bacterial (15-20%) 1) Salmonella - FOOD 12-36 hours after eating 2) C. difficile - HOSPITAL "antibiotics: 3) E. Coli - Food,H20,PPl "travelers diarrhea" • Parasitic (10-15%) 1 ) Giardia: Diarrhea (greasy stools that float), acquire through fecal oral route infected water normally • Food-borne toxigenic • Drug-associated 1) antibiotics 2) laxatives 3) Proton pump inhibitors
How does IBS manifest? What is common?
Manifestations: • Altered bowel habits • Abdominal pain • Abdominal bloating/distention
Common: • Postprandial urgency • Alternating between constipation and diarrhea, with one dominating per
individual patient • Intractability to laxatives • Defecation improves abdominal pain but doesn’t relieve it
Your patient comes in with diarrhea… what do you want to know about it?
Nausea Vomiting Abdominal cramping Abdominal bloating Fever
In stools, what are large volumes associated with and small volumes? white/bulky? copious rice water diarrhea?
large - enteric infection
small - colonic infection
white - small bowl pathology + malabsorption
rice water diarrhea: cholera
What are Cullen’s sign and Grey Turner’s sign indicative of?
o Cullen Sign: Ecchymosis around the umbilicus
(periumbilical) secondary to hemorrhage
o Grey Turner Sign: Flank ecchymosis secondary to hemorrhage
Percussion of liver location
Expected liver span: 6-12 cm at the mid-clavicular line on the right
Percussion of spleen location
Expected spleen span: from ribs 6-10 at the mid-axillary line on the left
